Transitional Care Management Services – Coding and Documentation

Since 2013, Medicare reimburses physicians for transitional care management (TCM). The new Medicare funds for TCM allow physicians to supplement their Medicare practice with the payment for the services they may already provide. However, appropriate physician coding and accurate documentation is essential to receive the correct payment without any delay. Coding for TCM services is challenging as the regulatory requirements for billing those services are significantly different from the rules for other services such as evaluation and management (E&M) services and procedures. The documentation must be sufficient to support beneficiary eligibility and delivery of the required services by a qualified provider.

TCM Codes and Their Use

You can bill for TCM using the following codes when discharging patients from inpatient hospital setting, partial hospital, observation status at a hospital and skilled nursing facility/nursing facility. The codes are not applicable for the discharge to a skilled nursing facility or community mental health center partial hospitalization program.

• 99495: Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge, Medical decision making of at least moderate complexity during the service period, Face-to-face visit within 14 calendar days of discharge.
• 99496: Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge, Medical decision making of high complexity during the service period, Face-to-face visit within 7 calendar days of discharge.

The crucial guidelines regarding the use of these codes include:

• You should bill for TCM services using these codes at the conclusion of the 30-day post discharge period.
• These codes are payable only once for each patient within the 30 days following the discharge. Thus, TCM cannot be billed again using these codes if the patient is readmitted.
• You should not use these codes with G0181 (home health care plan oversight) or G0182 (hospice care plan oversight) as the services are duplicative.
• You can apply the codes to both new and established patients.

Since only one individual can bill per patient using these codes, establishing the primary physician in charge of the coordination of care during this time period is very important.

Documentation Requirement

• Your documentation must specify that the particular beneficiary was discharged to domicile or community setting from inpatient acute care hospitals (inpatient, observation, and outpatient partial hospitalization), rehabilitation hospitals, long-term acute care hospitals, skilled nursing facilities and community mental health center partial hospitalization programs.
• In the case of moderate complexity, your documentation should support multiple diagnoses and/or management of options, moderate complexity of medical data to be reviewed and moderate risk of significant complications, morbidity, and/or mortality, as well as co-morbidities. For high complexity, the documentation should support extensive number of possible diagnoses and/or management of options, extensive complexity of medical data to be reviewed and high risk of significant complications, morbidity, and/or mortality, as well as co-morbidities.
• The documentation should include date of communication (or two failed attempts) and name and credentials of the individual who is making or attempting communication.
• Medical reconciliation should be performed no later than the date of face-to-face visit. Your documentation should be sufficient to support the fact that such services were provided.
• There should be sufficient documentation to support face-to-face visit including the date of visit.
• Your documentation should also support non face-to-face care management services as well.

Medical billing and coding experts can help enhance the accuracy of your coding and ensure comprehensive documentation.

OSI is a leading healthcare BPO company based in Tulsa, Oklahoma, focused on providing reliable medical billing and coding services.